Format Lap Keswa.docx
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REKAPITULASI LAPORAN KESEHATAN JIWA DINAS KESEHATAN DAN RUMAH SAKIT KAB/ KOTA ……………… Nama Instansi : Bulan/ Tahun :
No
Diagnosa
Jenis Kelamin
Usia 05-14th
Usia 15-24th
Usia 24-64th
LK
B
B
B
PR
L
L
L
Usia 64 th keatas B L
Rawat Inap
Rawat Jalan
Jumlah Total B
L
Jumlah
Mengetahui Kadinkes/Rumah Sakit
Pemegang Program Keswa
(..................................)
(......................................)
No
Diagnosa
Jenis Kelamin
Usia 05-14th
Usia 15-24th
Usia 24-64th
LK
B
B
B
PR
L
L
L
Usia 64 th keatas B L
Rawat Inap
Rawat Jalan
Jumlah Total B
L
Jumlah
Mengetahui Kadinkes/Rumah Sakit
Pemegang Program Keswa
(..................................)
(......................................)
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